Attorney Kay Van Wey
Hospitals Never Close: But Safety Sometimes Does
by Kay Van Wey, medical malpractice attorney.
Host of the AdvoKAYte: Holding Healthcare Accountable Podcast
Contact: kvw@vanweymetzler.com
“When we talk about increased risk of medical errors during weekends and holidays, it is critical to be clear: this is not simply a holiday problem. The underlying issue is safe staffing, a long-standing and well-documented patient safety concern in U.S. hospitals.”
—Kay Van Wey
I. Introduction
Some people joke that hospitals are like hotels, except with worse food. The food comparison may be fair, but a hospital stay is no vacation! No one wants to be hospitalized, much less to spend nights, weekends, or holidays there. And unlike hotels, hospitals hold patients’ lives in their hands.
Hospitals are, in theory, 24/7/365 operations. Patients reasonably assume that once admitted, the quality and safety of the care they receive will not depend on the day of the week, the time of day, or whether their hospitalization coincides with a holiday. Yet decades of empirical research demonstrate that this assumption is often incorrect.
Patient outcomes vary significantly based on timing. These variations include increased mortality, delayed treatment, higher complication rates, and failures in post-discharge follow-up. Within the patient-safety literature, these patterns are commonly described as the “Weekend Effect” and the “Holiday Effect.” The persistence of these findings across hospital systems, clinical disciplines, and study designs has firmly established this as a known and recurring problem rather than anecdotal coincidence.¹ ² ³
Understaffing during weekends and holidays exposes, and magnifies, systemic vulnerabilities that already exist within hospital staffing models and organizational culture. Safe staffing is not a new, speculative, or poorly defined concept. It is extensively studied, well understood by hospital leadership, and repeatedly emphasized by regulators, accreditation agencies, and professional organizations.¹ ⁴ ⁵
The continued tolerance of unsafe staffing raises fundamental questions about accountability, foreseeability of harm, and institutional priorities in American healthcare.
II. What Patients Have a Right to Expect
Patients enter hospitals, as many have experienced it, “naked and afraid.” Stripped of normal autonomy, dependent on strangers, and often acutely ill, patients know they are vulnerable. Many recognize when care does not feel coordinated, timely, or attentive. Yet most patients and families are powerless to do anything about it other than hope and pray that the system works as intended.z
Patients and families see firsthand that the quality of care varies from hospital to hospital, from unit to unit, and even from shift to shift within the same facility. They may sense when nurses are rushed, when calls go unanswered, or when critical information seems lost between providers. But they typically lack the knowledge or authority to intervene.
Frontline healthcare workers are often acutely aware of these breakdowns. Nurses, in particular, know when staffing levels are unsafe, when patient loads are unreasonable, or when skill mix is inadequate. Many want to do the right thing for their patients but feel trapped by management indifference or outright bullying that force impossible choices. These conditions do not excuse errors, but they explain how otherwise competent clinicians become instruments of system failure.
At a minimum, patients are entitled to hospitals that maintain a workforce that is competent, adequately trained, and sufficient in number to provide safe care. This is not an aspirational ideal, it is the baseline expectation on which licensure, accreditation, and reimbursement are built.
III. What Hospitals Know About Safe Staffing
The expectation that hospitals maintain safe staffing levels is embedded throughout the healthcare regulatory framework. Federal Conditions of Participation require hospitals to provide adequate nursing services and sufficient numbers of licensed personnel to meet patient needs.⁴ Accreditation standards, including those promulgated by The Joint Commission, reinforce that staffing decisions must be driven by patient acuity, complexity, and safety rather than cost minimization.⁵
Hospitals are not ignorant of the risks created by inadequate staffing. To put it bluntly: there are only so many things a nurse can do simultaneously for patients with competing and urgent needs. When staffing is insufficient, something or someone will inevitably fall through the cracks.
Excessive patient loads increase mental overload. Fatigue impairs judgment. Burnout degrades vigilance, responsiveness, and communication. These conditions predictably lead to missed diagnoses, delayed escalation of care, medication errors, deviations from safe practices, and breakdowns in coordination.⁵ ⁶
Equally important is how staffing occurs. Adequate numbers alone are insufficient if staff lack necessary experience or unit-specific competence. Assigning a nurse unfamiliar with dialysis equipment to a unit providing bedside dialysis, or placing an inexperienced nurse into a high-acuity specialty unit without support, may satisfy a numerical headcount while creating grave safety risks.
Staffing tools, acuity metrics, variance reports, and escalation protocols exist precisely because the dangers of unsafe staffing are foreseeable. Put simply, inadequate staffing is a real threat to patient safety.
IV. What Nurses Know Even when it is not visible to patients, the nurses know.
They are routinely placed between professional obligations to patients and institutional demands driven by productivity and cost control. Through advocacy and litigation, I have spoken with hundreds of nurses, those seeking guidance, those reporting burnout, and those examined under oath after catastrophic patient harm.
These accounts are disturbingly common:
• An ICU nurse typically assigned to 1:1 care is told she will be caring for 2 patients simultaneously, forcing her to contemplate which patient she would abandon if both decompensated at once.
• A novice nurse is assigned to manage bedside dialysis without training and told by management to “figure it out.”
• A surgical nurse improvises a drug dilution she has never prepared before, leading to a fatal decimal-point error.
• An OR nurse skips a time-out because of surgeon intimidation, missing a critical lab abnormality that would have stopped the procedure.
• A bedside nurse sees postoperative decline overnight but delays using the chain of command out of fear of the surgeon’s influence, until it is too late.
These scenarios underscore that many cases of patient harm emanate from decisions made in the C-suite. Staffing and assignment choices are often driven by cost containment, not clinical safety. This is one reason nurses and physicians are leaving the profession; they cannot safely practice without risking their licenses and their emotional well‑being.
V. Safety Culture Begins With Hospital Leadership
Patient safety is not simply a matter of individual professionalism. It is an organizational culture shaped by leadership.
Hospitals with strong safety cultures solicit frontline input, investigate near misses, and use adverse events for system improvement rather than individual blame. They communicate openly, conduct meaningful root-cause analyses, and foster environments where clinicians can speak freely.
Hospitals with poor safety cultures do the opposite, discouraging reporting, silencing clinicians, and normalizing unsafe practices. This is dangerous for patients.⁵
Lean staffing models that prioritize efficiency over safety leave no margin for patient surges, absences, or unexpected complications. Fatigue accumulates. Burnout accelerates. Safety collapses.⁵ ⁶
VI. The Scientific Evidence on Nurse Staffing
A landmark JAMA study by Aiken et al. found that surgical patients had:
• a 31% higher risk of death when nurses cared for more than seven patients, and
• a 7% increase in mortality for each additional patient added to the workload.⁶
Nearly 20,000 deaths annually were attributable to inadequate nurse staffing.
Subsequent research confirms that higher nurse staffing results in lower mortality, fewer hospital-acquired infections, reduced failure-to-rescue, lower readmissions, and shorter lengths of stay, even after adjusting for acuity and hospital characteristics.⁷ ⁸ ⁹
Staffing levels are not administrative details, they are clinical determinants of survival.
VII. The Weekend Effect: Two Hospitals Under One Roof
Although hospitals never close, the hospital a patient encounters on a weekday afternoon often looks very different from the one operating at night or on weekends.
Weekdays include full administrative support, nurse managers, educators, and specialists onsite. Diagnostics are faster. Escalation pathways function smoothly.
Weekends include reduced staffing, fewer specialists onsite, slower diagnostics, more handoffs, and thinner ancillary support.¹⁰
A major meta-analysis of 100 studies and 50 million patients confirmed significantly higher mortality for weekend admissions, even after adjusting for severity.¹⁰ These findings reflect system behavior, not patient composition.¹ ² ¹⁰
VIII. The Holiday Effect: Staffing Gaps and Fragmented Care
A BMJ study of 670,000 discharges found that patients discharged during December holidays were less likely to receive timely follow-up and more likely to experience ED visits, readmissions, or death within 30 days.¹¹
But follow‑up gaps are only one component.
Holidays frequently bring severe staffing shortages due to vacations, illness, hiring freezes, and reliance on temporary staff. Experience levels drop. Communication suffers. Contingency plans fail. Combined with fragmented outpatient infrastructure, risk escalates dramatically.
The resulting harm is foreseeable.¹¹
IX. This Is Not a Patient Problem
Patients cannot schedule emergencies around hospital staffing. Advising them to “avoid hospitalization during holidays” is not helpful.
Responsibility for safe staffing belongs to hospitals, boards, and executives, not patients. Regulators and professional bodies have repeatedly stated this.⁴ ⁵ ⁷
Understaffing is not accidental; it is a choice.
X. Speak Up, Nurses!
Nurses are uniquely positioned to identify unsafe conditions. The American Nurses Association Code of Ethics requires nurses to advocate for patient safety and act on threats to care quality.¹²
Provision 3 obligates nurses to “promote, advocate for, and protect the rights, health, and safety of the patient.”
Yet fear of retaliation silences many nurses, even when patient safety is at risk.¹² ¹³ ¹⁴
XI. Safe Harbor Laws: Texas and New Mexico
Texas and New Mexico provide statutory Safe Harbor protections.
• Texas Safe Harbor allows nurses to formally request peer review when assignments place patients at risk. Nurses are protected from retaliation and licensure action while the issue is investigated.¹³
• New Mexico provides similar protections for refusing unsafe assignments or reporting unsafe conditions.¹⁴
Most states lack equivalent safeguards for nurses, but most states have laws prohibiting retaliatory discharge. Nurses should seek legal counsel for individual situations. But fear of reprisal should not deter nurses from fulfilling their professional obligation to patient safety.
XII. The Joint Commission’s 2026 Staffing Initiative
The Joint Commission (TJC) holds Centers for Medicare & Medicaid Services (CMS) deeming authority, meaning hospitals must maintain accreditation to participate in Medicare, Medicaid, and most private insurance networks.
Each year, the Joint Commission sets a National Patient Safety Goal. These are evidence-based guidelines issued to address common, high-risk problems. The guidelines are intended to assist hospitals with methods to improve safety and reduce patient harm.
Beginning in 2026, TJC will require hospitals to:
• align staffing with patient acuity,
• demonstrate that staffing supports evidence‑based care,
• use adverse‑event and near‑miss data to evaluate staffing adequacy.¹⁵
Failure to comply risks accreditation deficiencies and potentially loss of Centers for Medicare & Medicaid Services (CMS) participation, an existential financial threat.
XIII. Hospital Liability for Unsafe Staffing
Hospitals may be held directly liable when unsafe staffing contributes to patient harm. Discovery should include:
• staffing grids and acuity tools
• staffing policies and competency records
• overtime and agency staffing data
• incident reports and RCA findings
• complaints, whistleblower reports, Safe Harbor filings
• Joint Commission deficiencies
If unsafe staffing contributed to injury, the hospital, not just individual clinicians, is legally accountable.
XIV. Conclusion
- Unsafe staffing is not new. Hospitals know what safety requires.
- Weekend and holiday spikes in harm are warning signals, not inevitabilities.
- Unsafe staffing is both a patient‑safety failure and a basis for accountability.
- Hospitals never close. But safety sometimes does.
References
1. Pauls LA et al. The weekend effect in hospitalized patients: a meta-analysis. J Hosp Med. 2017;12:760–766.
2. Ricciardi R et al. Mortality rate after nonelective hospital admission. Arch Surg. 2011;146:545–551.
3. Freemantle N et al. Weekend hospitalization and mortality. BMJ. 2015;351:h4596.
4. Centers for Medicare & Medicaid Services (CMS) Hospital Conditions of Participation, 42 CFR §482.23.
5. The Joint Commission. Comprehensive Accreditation Manual for Hospitals: Leadership and Staffing Standards.
6. Aiken LH et al. Hospital nurse staffing and patient mortality. JAMA. 2002;288:1987–1993.
7. Aiken LH et al. Nurse education and outcomes. Med Care. 2011;49:1047–1053.
8. Needleman J et al. Nurse staffing and inpatient mortality. N Engl J Med. 2011;364:1037–1045.
9. Griffiths P et al. Nurse staffing and mortality. BMJ Qual Saf. 2019;28:609–617.
10. Pauls LA et al. Weekend effect analysis. J Hosp Med. 2017;12:760–766.
11. Lapointe-Shaw L et al. Holiday discharge mortality. BMJ. 2018;363:k4481.
12. American Nurses Association. Code of Ethics for Nurses.
13. Texas Occupations Code §§301.352–301.356 (Safe Harbor).
14. N.M. Stat. Ann. §61-3 (nurse whistleblower protections).
15. The Joint Commission. 2026 National Patient Safety Goals.